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Predict Readmissions

Readmissions are expensive for hospitals. AI identifies who are the most likely to be readmitted to take preventive measures.

Problem

According to CMS, a readmission occurs when a patient is readmitted to the same or another acute care facility within 30 days of an initial hospital stay. Annually, adult patients experience 4.2 million hospital readmissions in the U.S., and among Medicare beneficiaries, one in six are readmitted within 30 days of discharge (1)(2). For older adults with functional impairments, the risk of readmission rises substantially and is 40% higher than the risk for a Medicare patient with no functional impairments (3).

Size of the Problem

  • 14,5 k is the average cost of a readmission.
  • 83% of general hospitals in the HRRP were penalized by CMS in 2019.
  • 40% of patients are discharged with pending test results.
  • 4,2 M adult hospital readmissions occur in the U.S. annually.

Why it matters

Readmissions are expensive. Hospital readmissions cost Medicare $26 billion annually with costs for readmissions of commercial payers and Medicaid beneficiaries amounting to $8.1 billion and $7.6 billion, respectively (4).They are also expensive for hospitals. CMS imposes a penalty on hospitals with excessive Medicare readmissions as part of the Hospital Readmissions Reduction Program (HRRP) and in 2019, penalized 2,583 hospitals $564 million for excessive 30-day hospital readmission rates (5).

The conditions that contribute most to readmissions differ for Medicare, commercial payers, and Medicaid, and the first step to managing them is identifying patients with these conditions who are the most likely to be readmitted (6). This also involves pinpointing any other reasons that patients might return to the hospital, which can include inadequate caregiver support, housing instability, food insecurity, or other social determinants of health. Using these insights to proactively work with patients, care teams can better plan transitions from hospital to home. When successful, such programs have been able to reduce readmissions by 34% (7).

Solution

Predictive analytics and AI can help healthcare organizations (HCOs) conduct successful care transitions, improve patient outcomes, and achieve their readmission reduction goals. AI-based models can help care teams identify high-risk patients, establish post-discharge PCP visits, ensure medication reconciliation to prevent adverse drug events, and provide appropriate support for patients with functional limitations. Bolstered by AI, such efforts can profoundly improve patient health outcomes and lower costs.

Datasources

  • ADT Records: Data from Admit, Discharge, and Transfer feeds and patient data notification services that synchronize patient demographic, diagnostic, and visit information across healthcare systems.
  • Rx Claims: Data extracted from health insurance pharmacy claims with details about each medication and its type, fill dates, days supply, pharmacy location, and prescribing clinician.
  • Social Needs Assessments: Self-reported data that identify an individual's specific needs and the acute social and economic challenges they are experiencing.

Citations

  1. Bailey, Molly K., et al. “Characteristics of 30-Day Readmissions, 2010-2016. Healthcare Cost and Utilization Project—Statistical Brief 4248. Agency for Healthcare Research and Quality, Feb. 2019. Accessed 13 Dec. 2020.
  2. All-Cause Admissions and Readmissions 2017 Technical Report” Department of Health and Human Services National Quality Forum, Sep. 2017. Accessed 14 Dec. 2020.
  3. Greysen, S. Ryan, et al. “Functional Impairment and Hospital Readmission in Medicare Seniors.” JAMA Internal Medicine, vol. 175, no. 4, 1 Apr. 2015, pp. 559-565, doi:10.1001/jamainternmed.2014.7756. Accessed 12 Mar. 2021.
  4. LaPointe J. 3 Strategies to Reduce Hospital Readmission Rates, Costs. RevCycleintelligence. Published January 8, 2018. Accessed March 23, 2021.
  5. Rau, Jordan. “New Round of Medicare Readmission Penalties Hits 2,583 Hospitals.” Kaiser Health Network, Oct. 2019. Kaiser Health News. Accessed 14 Dec. 2020.
  6. Hines, Anika L., et al. “Conditions with the Largest Number of Adult Hospital Readmissions by Payer, 2011. HealthCare Cost and Utilization Project=Statistical Brief 41727 Agency for Healthcare Research and Quality, Apr. 2014. Accessed 13 Dec. 2020.
  7. Kemp KA, Quan H, Santana MJ. Lack of Patient Involvement in Care Decisions and Not Receiving Written Discharge Instructions Are Associated with Unplanned Readmissions up to One Year. Patient Experience Journal. 2017:4(2). Accessed March 23, 2021.

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